My vision for ideal medical care is a partnership between the physician, patient, and expanded healthcare team that tackles the root causes of chronic disease and tries to reverse and prevent these problems.

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Saturday, September 3, 2016

Eliminating Conflicts of Interest in Medical Research

Who funds most of the studies that show that drugs are safe and effective? The drug companies themselves. It is self-evidently absurd to look to investor-owned companies for unbiased evaluations of their own products. One result of the bias in the medical literature is, then, that physicians learn to practice a very drug-intensive style of medicine—even when lifestyle changes would be more effective. Physicians and their patients often believe that for every ailment, there’s a drug.

It’s gotten so bad that physicians can no longer rely on the medical literature for valid and reliable information. Wow, that’s quite an accusation. Says who? Says a long-time editor of one of the most prestigious medical journals in the world.

To help expose some of these conflicts of interest that are corrupting the medical profession, the Drug Company Gift Disclosure Act was introduced into Congress, and died there year after year, until it was successfully integrated into the Affordable Care Act. And now, there’s a database detailing which doctors get the billions of dollars dished out, permitting patients to make better informed decisions when choosing health care professionals, and making treatment decisions. I described how you could look up your own doctor.

The 2008 version that medical groups endorsed didn’t require public disclosure, unless doctors got $500 in gifts. But the 2009 version got even stricter, requiring disclosure if you even pocketed $100; leading groups like the American Academy of Family Physicians to start to get a little nervous. But the final wording in Obamacare requires disclosure of even a $10 meal, leading countries around the world to look to the United States of America for leadership in health care ethics—you don’t see that every day.

Now that we have this massive public record, we can now really see how honest doctors have been. The financial disclosures by the authors of the American College of Cardiology and American Heart Association guidelines were matched to the public disclosures of the hundreds of thousands of dollars they received from Big Pharma, thanks to the new law. And let’s just say the overall agreement between author and company disclosure was poor.

Nationally, female physicians each received thousands fewer dollars, on average, each year from drug companies—though it’s not clear if this is because the women were ethical, or the industry was sexist.

What about conflicts of interest online? There are purportedly evidence-based medicine websites allowing physicians to answer clinical questions at the bedside. For example, clinicians caring for patients are increasingly reviewing treatment recommendations on these websites to make clinical decisions in real time. You’re with a patient; you can just whip out your phone and check. So, it’s important that there are no financial conflicts of interest in those that write these online guidelines. So, they examined one such website called UpToDate, which seemed to provide the most comprehensive diagnoses. So, did they find any conflicts of interest? Yes, in every single one they looked at.

Okay, but so what do you do with that information? Let’s say you see an article claiming that candy consumption is not associated with health risks, and they disclose that the research was supported by the National Confectioner’s Association—who used to run ads that said things like: “Put candy in their school lunch because it’s good for them.” The problem with financial conflicts of interest is that you simply don’t know what to believe.

So, maybe this preoccupation with disclosure hijacked the whole debate. Maybe, as the former editor-in-chief of the New England Journal of Medicine critiqued, the focus should be instead on not just disclosing, but eliminating commercial conflicts. It’s like campaign finance reform, where the issue is managed more by public disclosure, rather than getting money out of politics.

Dr. Kassirer writes that the vast attention paid to failure to disclose conflicts of interest is misplaced, and that more attention should be focused on the financial conflicts themselves. After Dr. Kassirer effectively resigned from the New England Journal of Medicine, disillusioned with the direction they were taking, Dr. Angell took over. The first female editor-in-chief in the journal’s hundred year history. She lasted about a year. Medical journals “consistently refer to ‘potential’ conflicts of interest,” she wrote, “as though that were different from the real thing, and about disclosing and ‘managing’ them, not about prohibiting them. In short, there seems to be a desire to eliminate the smell of corruption, while keeping the money. Breaking the dependence of the medical profession on the pharmaceutical industry will take more than appointing committees. It will take a sharp break from an extremely lucrative pattern of behavior.”

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